HIPAA Compliance Consent Form

In an effort to protect the health of employees and guests, our member properties can elect to require all visitors to complete a COVID-19 Survey and/or agreeing to Waiver of Liability form before entering the property.

CellarPass is committed to maintaining consumer privacy. This notice is being used to properly inform those that are required to complete these forms on how we store and how our member properties may use or disclose protected health information.

The notice contains a consumer's rights section describing your rights under the law. You ascertain that by completing the form, you have reviewed our notice and have agreed upon the terms prior to submitting your consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your consent.

You have the right to restrict how your protected health information is used and disclosed for visitation. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By using our platform, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By submitting this consent form, I understand that:

• Protected health information may be disclosed for visitation purposes only.
• Protected health information will not be shared with any 3rd parties (other than CellarPass) for the sole purpose of visiting a member property.
• CellarPass or our member properties reserve the right to change the privacy policy as allowed by law.
• CellarPass or our member properties has the right to restrict the use of the information but does not have to agree to those restrictions.
• The guest has the right to revoke this consent in writing to the member property at any time and all full disclosures will then cease immediately.

Furthermore, a member property reserves the right to cancel your visit should you or your additional guests fail to complete the required COVID-19 Survey and/or Waiver of Liability prior to arrival.